Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the optimal management of patients with stage II lung cancer without nodal metastasis, but unresectable due to poor pulmonary reserve?
This population of stage II patients without nodal involvement would include T2bN0 (stage IIA) or T3N0 (stage IIB) disease. NCCN 2020 lists either CRT or hypofractionated RT/SBRT as acceptable options. In my experience, if these patients are nonsurgical, then they typically also have multiple co-mor...
Would you offer contralateral prophylactic mastectomy in an older BRCA1 + woman who is getting treated for newly diagnosed BC with mastectomy and SLNB?
Women with deleterious mutations in BRCA1 typically develop triple negative breast cancers. There is a not-insignificant risk of breast cancer in the contralateral breast after a diagnosis of breast cancer. This risk is as high as 20% within 5 years of the primary diagnosis. Even if detected early, ...
Are you de-escalating treatment for favorable risk Stage I-II DLBCL patients to 4 cycles of R- CHOP with 2 additional rituximab cycles?
In general I could see this being an option in select patients (not localized stage II or patients who have a contraindication to XRT) but for the most part these patients in my practice are not treated with 6 cycles of R-CHOP. I treat most patients with Stage I and localized stage II with 3 cycles ...
When, if ever, do you use gemcitabine + erlotinib in patients with metastatic pancreatic cancer?
Never. The benefit in the phase 3 was <10-days without any outstanding responders. Maybe if NGS showed Ras-wildtype and suggested EGFR was a driver.
Is there a role for upfront next generation sequencing in extensive stage small cell lung carcinoma?
The current standard of care is a combination of chemotherapy and immunotherapy (platinum-etoposide with atezolizumab; durvalumab may be an option as well based on the CASPIAN trial). There are no data for targeted therapy, nor is there any evidence to support using any biomarkers to guide immunothe...
Are PD-L1 and molecular markers from pleural fluid specimens reliable enough to guide decision making in metastatic NSCLC?
There is some good data to support the adequacy of malignant pleural effusion specimens as a source of tissue to detect actionable molecular and genetic alterations, if the cellularity of the cell block made from the fluid is adequate (Yang S-R, et al., J Mol Diagn 2018 is one such example). Many la...
Are you testing for PD-L1 IHC expression in extensive stage small cell lung cancer who are planned to be treated with chemotherapy plus immunotherapy?
Based on trial approved chemo-immunotherapy for ES-SCLC, it is not a requirement. IMpower33 (Atezo) and Caspian trial (durva).
What is the optimal duration of ADT for cN1 disease with EBRT?
Unfortunately there are no prospective data to guide management for cN1 prostate cancer treated with EBRT. The NCCN guidelines do not comment on the optimal duration of ADT in this setting. While 18 months may be considered for some patients with high risk cN0 prostate cancer as per the PCS IV trial...
What are the options of induction treatment of young AML patients who are on CRRT, continuous renal replacement therapy ?
Hypomethylating agent like decitabine and venetoclax will be good options. C1 decitabine for 10 days and venetoclax for 28 days. Then C2 decitabine for 5 days and venetoclax every 28 days. Bone marrow biopsy should be done on day 21. There is, however, no strong literature support regarding pharmaco...
Are EGFR exon 20 insertion mutations in lung cancer predictive of a poor response to immunotherapy?
Exon 20 insertion mutations are predictive of a poor response to approved EGFR TKI therapies, but little data exists regarding responsiveness to immunotherapy for these patients. A 2018 ASCO presentation (1) showed better efficacy with ICIs in patients with exon 20 insertions compared to patients wi...